South Salinas hospital moving quickly to resolve issue after state complaint goes unanswered for a decade

Oct. 4, 2013

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Under the Dome

First, let’s just establish that hospitals are complicated enterprises.

They have a million moving parts and they have to function well all of the time. The margin of error they operate within is razor thin.

And just like with aircraft, things can go from great to bad – in, well, a heartbeat – if one of those moving parts fails.

So those are the caveats.

So when I tell you that documents obtained by The Californian show Salinas Valley Memorial Hospital’s backup emergency power generator went a full decade in an unlicensed and unpermitted state but yet never once failed, you may ask yourself, so what?

To be sure, the idea of the main grid power going out and a hospital’s backup generator failing invokes images of medical procedures being interrupted, evacuations and electric device-dependent patients slowly dying ŕ la the hospitals in New Orleans during 2005’s Hurricane Katrina.

Fast-forward to last fall when what was called Superstorm Sandy knocked out main power and disabled backup generators at New York University’s Langone Medical Center. There in the middle of the night and in the middle of a fierce storm, hospital staff had to evacuate all 215 patients with flashlights.

No harm, no foul?

So the question becomes: Should anyone care that SVMH allowed this situation to go unresolved for 10 years?

It’s kind of like that old philosophical question, “If a tree falls in a forest and no one is around to hear it, does it make a sound?”

It’s essentially a “No harm, no foul” thing, right?

Or is it?

Since no one – over the entire decade-long period – was ever harmed by the issue, this then becomes a case of the “What ifs” – as in what if main power had failed and what if SVMH’s emergency generator failed?

It also becomes, to a degree, a case study in how SVMH looks at regulatory compliance – or, at least how it did look at it, that is.

For state regulators, however, the “What ifs” do count. That’s the world they live in, and thank God for it.

A review of correspondence and documents between SVMH and the California Office of Statewide Health Planning and Development (OSHPD) and the state Department of Public Health documents shows that the current generator is out of compliance, unpermitted and yet has been continuously relied upon since OSHPD first notified SVMH about it in 2003.

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“(OSHPD) appreciates the efforts that SVMH has made toward seismic safety compliance. However, a seismically safe acute care hospital building will be rendered unusable by the loss of its essential electrical systems should normal power fail, which often occurs during a strong seismic event. A loss of the normal and essential electrical systems will place patients’ lives in jeopardy, especially those on electrical life support systems (or those) undergoing invasive medical procedures, and it will make an orderly evacuation of the hospital extremely difficult,” OSHPD Deputy Director Paul Coleman wrote to Lowell Johnson, SVMH’s former interim CEO, in a Jan. 22, 2013, letter.

Then on March 5 the state Department of Health stepped in and issued SVMH a formal “statement of deficiency and plan of correction,” basically a written citation punctuating the concerns of their OSHPD colleagues.

SVMH representatives say that the generator on the grounds is rigorously tested – on a weekly, monthly and yearly basis for different intervals and under differing stress conditions. The dang thing, illegal as it may be, has never failed in all that time.

Vulnerability to earthquakes

But state officials say what concerns them the most is where the generator is located – inside a semi-truck trailer resting on its original rear wheels.

In other words, they’re worried about it being prone to being knocked over or damaged in the event of a bad earthquake, leaving the hospital without any kind of power and helpless.

After all, the trailer is sandwiched between two lengths of concrete K-rail (like the ones used in highway construction) that weigh several tons each. Then, thick steel cables have been looped securely through the K-rail to the bottom and the sides of the trailer.

Although the greater southwestern Salinas area is subject to periodic winter flooding by the Salinas River, SVMH sits on a slightly elevated parcel that is not thought to be flood prone. Likewise, the location of the 269-bed medical institution sits on what is thought to be earthquake fault-free land.

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So knowing all this, SVMH is seeking to build first a temporary semi-permanent emergency backup generator station that will cost close to $1 million.

Following that, in about two years’ time, SVMH will build an elevated, permanent and fully regulatory-compliant generator station that, it’s hoped, will be largely impervious to Mother Nature’s tantrums. That building will cost an estimated $7.5 million or more.

First, though, the hospital has secured a temporary permit from state officials to continue to rely on the temporary generator housed in the trailer until the permanent unit can be installed and operated.

"It's complicated"

The question remains: How did this problem go ignored for a whole decade?

The short answer, SVMH representatives say, is it’s complicated.

Shifting management, retirements and other personnel movements apparently had OSHPD’s original 2003 warning moving from desk to desk and, over time, it fell off the radar.

SVMH representatives say their people were also in a jam to push forward a state-mandated but unfunded earthquake retrofit program of the main campus that ended up costing the institution a whopping $42 million.

Experts I spoke with this about this situation were largely sympathetic to SVMH’s position.

“It sounds like it got buried,” said Dr. Dan Hanfling, a board-certified trauma center physician and special adviser to Inova Health System in Falls Church, Va., a suburb of Washington, D.C. “I’m not making excuses for them, but I can understand how this can happen.

“That said, not only does the generator system need to get fixed, but I’d say SVMH also needs to look carefully as to why this issue was ignored for so long,” said Hanfling, an internationally acknowledged expert on hospital emergency preparedness and who, as a physician, served on federal emergency response teams deployed to disaster zones in Turkey in 1999, the Pentagon during 9/11, Hurricanes Rita and Katrina in 2005 and Hurricanes Gustav and Ike in 2008. Most recently, he participated in the response to the devastating earthquake in Haiti in 2012.

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Hanfling added that a hospital’s emergency backup power system is a “leading indicator” as to a facility’s given level of disaster preparedness.

“Power and water are your two primary ‘mission critical’ components – without them you’re in trouble,” he said.

Hanfling also noted that in today’s healthcare industry, the dollars needed to support a given institution’s expensive infrastructure needs are scarce, and government is famous for providing little funding for such things as earthquake retrofitting or making sure an emergency electrical backup system is reliable and meets all regulatory requirements.

Once problem surfaced, reaction was swift

So last December, when the issue that SVMH’s backup power system was illegal, unpermitted and a decade out of compliance hit the SVMH board of directors, action by those electeds and by the hospital’s top executives, to their credit, was fast. I mean really fast.

Board President Harry Wardwell and board treasurer Jim Gattis both became so personally concerned that they drove to Sacamento to meet with OSHPD officials. They then ordered an internal investigation into the matter.

A subsequent March 25 report to the board by Lisa Paulo, SVMH director of revenue integrity and compliance, said that some 60 SVMH internal documents and nine outside regulatory documents on the generator issue were reviewed to try and figure out what happened.

“(The California Department of Health’s notice of compliance) prompted a series of urgent meetings/ communications to determine an appropriate response and plan of correction. On Feb. 25 the information known to date was presented and discussed. A resounding question surfaced and continued to (be) present throughout the next several meetings: Why was the licensing risk not communicated to the board?” Paulo wrote in her report.

Paulo identified these elements, among others, as possible reasons the 2003 notice by OSHPD was ignored:

• A focus on implementing and completing a $42 million state-required but unfunded seismic upgrade drew much of the staff’s attention and energies.

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• Retirements and transitions of many of the hospital’s key leaders may have hampered the generator issue from staying top of mind.

I asked the regulators at OSHPD in Sacramento – the same agency that rode herd on SVMH on the earthquake retrofit issue – why it took them a decade to follow up on their initial 2003 finding.

Their answer may sound a little familiar:

“Under normal circumstances, OSHPD field staff staff would have followed up with the hospital during visits to ensure resolution and compliance with building codes. Due to staff turnover, it is unclear whether follow up by OSHPD’s field staff occurred after the initial report,” OSHPD spokesman David Byrnes wrote in an email to The Californian.

And sources at SVMH I have spoken with say there is no evidence that the state agency ever did a follow-up with them on the generator issue until late last year.

New CEO Pete Delgado, however, said he almost doesn’t care about how SVMH got into the predicament it’s in with the generator.

Delgado, who came aboard in April, said what he cares most about is getting it fixed and making sure something like this never happens again.

To that end, Delgado said, the health care district hired a new regulatory compliance officer, Sylvia Lozano, and that he has subsequently made it clear to top executives that he wants to be put directly in the loop on such matters – matters that could ultimately affect SVMH’s operating license.

“What is past is past. What I’m all about is communicating to our staff that if there’s a problem or an issue that they’re worried about – especially one that could impact our license – they are to come forward directly to me,” Delgado said in an interview.

I say bravo to Delgado and to Gattis and Wardwell for their response to a potentially critical issue.

Meanwhile, an SVMH publicist told me this week that the district is awaiting approval from OSHPD to begin construction on what will be the new semi-permanent emergency power backup station. The representative told me SVMH hopes to hear back from the state agency by the end of this month.

SVMH is going through the request for proposal phase for designs for the bigger, permanent and more expensive backup generator site. Once a final design is picked, that project will be quickly forwarded to OSHPD in Sacramento for approval. Again, that process is about two years out.

Finally, it was unclear from documents released late Thursday by Monterey County whether the generator issue had any impact on an independent panel’s recommendation that county-owned Natividad Medical Center, not SVMH, be designated as a Level II Trauma Center. Both institutions were in heavy and close competition for the designation.

Jeff Mitchell covers Salinas Valley politics and government. Under the Dome, an opinion column, appears Tuesday, Thursday and Saturday in both print and online. For quick political hits, check out Under the Dome - The Blog which is at: www.theCalifornian.com is available most every day.